Dual-lumen Venovenous Extracorporeal Membrane Oxygenation Research Articles

Similar frequency of atrial perforation between atrial and bicaval dual lumen veno-venous ECMO cannulas in a pediatric population.

Complications associated with use of dual-lumen venovenous extracorporeal membrane oxygenation (VV-ECMO) cannulas are of concern in pediatric patients. While the risk of atrial perforation is believed to be higher with bicaval cannulas, direct comparison of complication rate between atrial and bicaval cannulas has not been conducted in this population. A retrospective review was conducted at a free-standing children's hospital of all patients 0-18 years old, placed on VV-ECMO with a dual-lumen cannula from January 2009 to December 2018. Patients were grouped based on cannula type. Complications were assessed over the entire duration of the ECMO run. Logistic regression analyses were used to evaluate for an association between cannula type and risk of pericardial effusion or cannula-related complication requiring median sternotomy or pericardial drain placement. During the study period 119 patients were placed on VVECMO using a dual-lumen cannula. Eighty-two patients (69%) were <2 years old, 19 (16%) were 2-10 years old, and 18 (15%) were 11-18 years old. Seventy-three were cannulated with an atrial cannula and 46 patients received a bicaval cannula. Pericardial effusions were seen in 30% and 24% of these patients respectively while severe complications were seen in 9.6% and 8.7% of patients respectively. Compared to patients treated with a bicaval cannula, those who received an atrial cannula had similar odds of effusions (OR: 1.41, 95% CI: 0.62-3.36) and severe complications (OR 0.89, 95% CI: 0.27-3.18). After adjusting for age, weight, cannula and circuit manipulations, and use of echocardiography, the OR of effusion was 1.91 (95% CI: 0.65-6.42), and the adjusted OR of severe complication was 0.69 (95% CI: 0.16-3.33). There were no significant differences in frequency of pericardial effusions or severe cannula-related complications between the treatment groups across all pediatric patients and within the subgroup of patients under 2 years of age.

A Dual-Lumen Bicaval Cannula for Venovenous Extracorporeal Membrane Oxygenation

Single-site, dual-lumen venovenous extracorporeal membrane oxygenation ECMO) facilitates mobilization, reduces recirculation, and mitigates insertion and infectious risks of an additional access site. This study reports the experience with a bicaval dual-lumen cannula that comprises a robust physical design allowing for easy and safe cannulation, precise positioning and monitoring, and appropriate physiologic support for patients with acute respiratory failure. Statistical analysis was performed from data gathered retrospectively from the electronic medical records of 20 adult patients who were cannulated for ECMO with this bicaval dual-lumen cannula from August 2018 through May2019. Gas exchange and blood flow were optimized in all patients after cannulation (median pH, 7.42 [interquartile range {IQR}, 7.39, 7.44], ratio of arterial partial pressure of oxygen to fraction of inspired oxygen, 186.5 [Pao2:Fio2, 116.5, 247.0]; pump flow, 3.9 L/min [IQR, 3.1, 4.3]). Eleven patients (55%) were able to be freed from mechanical ventilation after cannulation, 9 (45%) patients underwent a tracheostomy procedure while undergoing ECMO, and no patients required reintubation. No morbidity or mortality was related to the cannulation strategy or the catheter. Two patients required cannula repositioning. Survival to decannulation was 90%, and survival to hospital discharge was 80%. The bicaval dual-lumen cannula maintains the advantages of upper body single-site configuration to provide the adjunctive respiratory support necessary to facilitate awakening and rehabilitation while minimizing the use of invasive mechanical ventilation. This cannula introduces design qualities that may offer advantages for acute respiratory failure requiring venovenous ECMO.

Echocardiography-Guided Dual-Lumen Venovenous Extracorporeal Membrane Oxygenation Cannula Placement in the ICU—A Retrospective Review

The most effective method of image guidance for venovenous extracorporeal membrane oxygenation is not known. The authors' objectives were to define the frequency of successful initial cannulation using echocardiographic guidance in the intensive care unit, as well as to determine the frequency of subsequent adjustments. Additional aims were to illustrate cannula malposition problems and to describe features associated with difficult cannulation. Retrospective consecutive case series analysis. Single tertiary care university hospital. Forty-five patients treated with venovenous extracorporeal membrane oxygenation. None. The most common causes of respiratory failure were pneumonia, aspiration, and inhalational burn injury. Sixty-two percent survived to discharge. Initial cannulation was successful in 39 cases (87%). Adverse events included 5 cases of cannula malposition and 1 case of hemorrhagic shock. During the course of extracorporeal membrane oxygenation, 17 patients (38%) required echo-guided cannula position adjustments. There were no fatal complications. Factors associated with difficult cannulation included extremes of size, a prominent Eustachian valve, and an anterior guidewire bending in the right atrium. Younger age was associated positively with survival. There was no significant association between adverse events during cannulation and survival. Dual-lumen venovenous extracorporeal membrane oxygenation cannulation in the intensive care unit under echo guidance has a high initial success rate, but many patients require subsequent repositioning. Echocardiography can define cannula position in sufficient detail to identify malposition precisely and to guide repositioning.

Use of venovenous ECMO for neonatal and pediatric ECMO: a decade of experience at a tertiary children's hospital.

Advances in extracorporeal membrane oxygenation (ECMO) have led to increased use of venovenous (VV) ECMO in the pediatric population. We present the evolution and experience of pediatric VV ECMO at a tertiary care institution. A retrospective cohort study from 01/2005 to 07/2016 was performed, comparing by cannulation mode. Survival to discharge, complications, and decannulation analyses were performed. In total, 160 patients (105 NICU, 55 PICU) required 13 ± 11days of ECMO. VV cannulation was used primarily in 83 patients with 64% survival, while venoarterial (VA) ECMO was used in 77 patients with 54% survival. Overall, 74% of patients (n = 118) were successfully decannulated; 57% survived to discharge. VA ECMO had a higher rate of intra-cranial hemorrhage than VV (22 vs 9%, p = 0.003). Sixteen VA patients (21%) had radiographic evidence of a cerebral ischemic insult. No cardiac complications occurred with the use of dual-lumen VV cannulas. There were no differences in complications (p = 0.40) or re-operations (p = 0.85) between the VV and VA groups. Dual-lumen VV ECMO can be safely performed with appropriate image guidance, is associated with a lower rate of intra-cranial hemorrhage, and may be the preferred first-line mode of ECMO support in appropriately selected NICU and PICU patients. II.

Catheter-directed guidance for ECMO cannulation with unfavorable caval anatomy

Extracorporeal membrane oxygenation (ECMO) has become the standard of care for potentially reversible cardiopulmonary conditions intractable to conventional medical management. Single site, dual-lumen veno-venous ECMO has proven to be safe and advantageous with respect to mobilization of the patient. Nevertheless, adequate respiratory support demands optimal cannula positioning and catastrophic cannulation complications have been reported. We describe herein the utilization of an angulated guiding catheter to obtain trans-caval access for the successful placement of a single site dual-lumen cannula for veno-venous ECMO in a patient with unfavorable trans-caval anatomy.

Safety of intensivist-led bedside decannulation of internal jugular bi-caval dual-lumen veno-venous extracorporeal membrane oxygenation cannulas and report of technique.

In the past decade, the rate and utilization of veno-venous extracorporeal membrane oxygenation (VV-ECMO) has increased dramatically. A single catheter technique has recently come into favour for providing VV-ECMO. Although it has been shown that intensivists can safely place these catheters, the safety of decannulation by intensivists has not been reported in the literature. We describe a technique for safely decannulating the Avalon Elite VV-ECMO catheter at the bedside and assess the safety of this technique, as compared with the standard technique of decannulation in the operating room by a surgeon. This was a retrospective cohort design conducted at a tertiary care cardiovascular intensive care unit at an academic medical centre. All patients who underwent VV-ECMO from 2009 to 2014 were included in the study except for those who had been decannulated for withdrawal of care. Complication rates from decannulation were compared between patients who were decannulated by surgeons in the operating room and those decannulated by intensivists in the intensive care unit (ICU). Twenty-eight patients were included in this study, of whom twenty-three patients (82%) were decannulated by intensivists, board certified in Critical Care Medicine through the American Board of Anesthesiology, while five (18%) the patients were decannulated by a surgeon. There was no significant difference in the complications rates between the surgeons (0) and intensivists (1) (P = 1.00). There were no major complications requiring operative intervention associated with decannulation identified in this study. It is safe for intensivists to decannulate the Avalon Elite VV-ECMO cannula in the ICU using our purse-string suture technique. Performing these decannulations at the bedside compared to operating room may have positive clinical ramifications that include improved patient safety, timely patient care and reduced operating room costs.

Initial Experience With Single-Vessel Cannulation for Venovenous Extracorporeal Membrane Oxygenation in Pediatric Respiratory Failure*

Venovenous extracorporeal membrane oxygenation has been used to provide cardiopulmonary support in critically ill infants and children. Recently, dual-lumen venovenous extracorporeal membrane oxygenation has gained popularity in the pediatric population. Herein, we report our institutional experience using a bicaval dual-lumen catheter for pediatric venovenous extracorporeal membrane oxygenation support, which has been our unified approach for venovenous extracorporeal membrane oxygenation since 2009. This study is a retrospective review. The setting is a tertiary children's hospital in a major metropolitan area. Between 2009 and 2011, 11 patients were cannulated using a dual-lumen bicaval venous catheter. Patient demographics, cannulation details, circuit complications, complications of catheter use, and patient outcomes were collected from a retrospective chart review. None. Eleven of the patients were cannulated for venovenous extracorporeal membrane oxygenation using the dual-lumen bicaval cannula. The median age at the time of venovenous cannulation was 1.9 years (range, 0.14-17.1), and the median weight was 10.2 kg (range, 3-84). Three patients (27%) required conversion to venoarterial extracorporeal membrane oxygenation. The median duration of extracorporeal membrane oxygenation support was 10 days (2-38 days). Fifty-five percent of patients suffered from a bleeding complication (disseminated intravascular coagulation, pulmonary hemorrhage, or intraventricular hemorrhage), and 45% had a circuit complication. Adequate flow rates were achieved in all patients. The overall hospital mortality in the series was 55%. There were no cannula-related complications. This review presents the first single-institution experience with the dual-lumen Avalon cannula in pediatric patients. Preliminary results indicate that the catheter can be safely placed and has an acceptable complication profile; however, continued study within larger trials is necessary to fully ascertain the clinical profile of this catheter.

High incidence of upper-extremity deep vein thrombosis with dual-lumen venovenous extracorporeal membrane oxygenation

Venovenous extracorporealmembrane oxygenation (ECMO) has emerged as an important intervention for patients with acute respiratory failure, as well as as a bridge to lung transplantation for end-stage lung disease. A recently introduced bicaval, dual-lumen cannula appears to be a promising technologic advancement for venovenous ECMO support. Introduced percutaneously through the right internal jugular or left subclavian vein, the Avalon Elite cannula (Avalon Laboratories, Rancho Dominguez, Calif) selectively drains venous blood from the inferior and superior venae cavae and infuses oxygenated blood directly into the right atrium. Advantages of this cannula include a single insertion and upper body placement, which can allow ambulation to maintain patient conditioning.Although the cannula is available inmultiple sizes (23-31F), clinical experience has shown that larger cannula sizes are required to generate adequate flow for respiratory support in adults (>4.0 L/min). Larger cannulas used for extended durations, however, probably predispose the patient toward upper-extremity deep venous thrombosis (DVT). We evaluated the incidence and subsequent clinical implications of upper extremity DVT in patients who were supported with venovenous ECMO by means of the Avalon dual-lumen cannula.

Mechanical Support for Pulmonary Veno-occlusive Disease: Combined Atrial Septostomy and Venovenous Extracorporeal Membrane Oxygenation

The use of atrial septostomy for refractory pulmonary hypertension and right ventricular failure results in an adequate left ventricular preload and improved cardiac output at the expense of a profound hypoxic shunt. Combined dual-lumen venovenous extracorporeal membrane oxygenation and atrial septostomy provides extracorporeal gas exchange of venous return before the directional right atrial to left atrial shunt, can be deployed percutaneously, and results in an ambulatory patient with stable hemodynamics.